Justia Public Benefits Opinion Summaries

More than a decade ago, Medicaid recipients filed this suit alleging that in violation of the Due Process Clause, the District of Columbia is failing to provide them notice and an opportunity to be heard when denying them prescription coverage. The case is now before the DC Circuit for the third time. In the first two appeals, the DC Circuit reversed the district court’s dismissals for lack of standing and for failure to state a claim, respectively. On remand, the district court once more dismissed the case, this time for mootness.   The DC Circuit again reversed and remanded with instructions to proceed expeditiously with discovery and allow Plaintiffs to make their case. The court explained that Plaintiffs challenged the District’s failure to give Medicaid recipients reasons for denying their prescriptions and an explanation of how to appeal, and uncontested evidence demonstrates that, notwithstanding the transmittal memorandum, some number of Plaintiffs are still not receiving the information they claim they are entitled to under the Due Process Clause. Because it is not “impossible for [the district] court to grant any effectual relief,” the case is not moot. View "Elsa Maldonado v. DC" on Justia Law

The Northern Arapaho Tribe and the Indian Health Service (IHS) entered into a contract under the Indian Self-Determination and Education Assistance Act for the Tribe to operate a federal healthcare program. Under the contract, the Tribe provided healthcare services to Indians and other eligible beneficiaries. In exchange, the Tribe was entitled to receive reimbursements from IHS for certain categories of expenditures, including “contract support costs.” The contract anticipates that the Tribe will bill third-party insurers such as Medicare, Medicaid, and private insurers. The Tribe contended that overhead costs associated with setting up and administering this third-party billing infrastructure, as well as the administrative costs associated with recirculating the third-party revenue it received, qualified as reimbursable contract support costs under the Self-Determination Act and the Tribe’s agreement with the IHS. But when the Tribe attempted to collect those reimbursements, IHS disagreed and refused to pay. Contending it had been shortchanged, the Tribe sued the government. The district court, agreeing with the government’s reading of the Self-Determination Act and the contract, granted the government’s motion to dismiss. A divided panel of the Tenth Circuit Court of Appeals voted to reverse (for different reasons). Under either of the jurists' interpretations, the administrative expenditures associated with collecting and expending revenue obtained from third-party insurers qualified as reimbursable contract support costs. View "Northern Arapaho Tribe v. Becerra, et al." on Justia Law

May is a disabled child of a deceased veteran. The VA found that May was disabled from birth, with permanent incapacity for self-support, and granted him entitlement to dependency and indemnity compensation (DIC) benefits in October 2018, with an effective date of May 18, 2016, concluding that May’s entitlement to DIC benefits ended on February 1, 2017, when he married. May sought reinstatement of DIC benefits based on his divorce. May filed a notice of appeal to the Veterans Court in February 2021, listing the date of the Board’s decision as February 19, 2019. The Board had not rendered a decision on February 19, 2019; rather, May had received correspondence that day from a VA regional office certifying an appeal to the Board.The Veterans Court ordered May to show cause why his appeal should not be dismissed. In letters, May asked that his appeal not be dismissed and that his benefits be reinstated. May did not identify a Board decision from which he was appealing, nor did he argue that the Board had unreasonably delayed its decision. The Federal Circuit affirmed the dismissal of the appeal for lack of jurisdiction. The court’s jurisdiction is limited to appeals from Board decisions; absent such a decision, it could not consider May’s appeal, 38 U.S.C. 7252(a), 7266(a)). View "May v. McDonough" on Justia Law

Petitioners PF Sunset Plaza, LLC (“Sunset Plaza”) and PF Holdings, LLC (“Holdings”) were each assessed monetary penalties by the Department of Housing and Urban Development (“HUD”) for violations of their duty to provide “decent, safe, and sanitary housing” to low-income families under Section 8. Petitioners petitioned to reverse ALJ decisions dismissing these HUD enforcement actions against them for lack of subject matter jurisdiction. At issue on appeal is whether the statute operates to bar the appeal of a civil monetary penalty should a respondent miss the fifteen-day deadline to request an administrative hearing?   The DC Circuit answered yes, and denied both petitions. The court explained that Petitioners claim that because the deadline falls under a subheading entitled “Final Orders,” a final order from HUD must occur before operation of the deadline commences. Petitioners argued that HUD’s issuance of a complaint is simply an invitation to engage in litigation, not a triggering of the fifteen-day deadline. Because HUD issued no final order here, they contest that the fifteen-day period never began. The court held that Petitioners misunderstand the statutory subheading. Congress entitled the section “Final Orders” because it enumerates two examples of how HUD’s penalties become final. View "PF Holdings, LLC v. HUD" on Justia Law

Approximately 30 years after Arellano’s honorable discharge from the Navy, a VA regional office granted Arellano service-connected disability benefits for his psychiatric disorders. Applying the default rule in 38 U.S.C. 5110(a)(1), the VA assigned an effective date of June 3, 2011—the day that it received Arellano's claim—to the award. Arellano argued that the effective date should be governed by an exception in section 5110(b)(1), which makes the effective date the day following the date of the veteran’s discharge or release if the application “is received within one year from such date of discharge or release.” Alleging that he had been too ill to know that he could apply for benefits, Arellano maintained that this exception’s one-year grace period should be equitably tolled to make his award effective the day after his 1981 discharge.The Board of Veterans’ Appeals, Veterans Court, Federal Circuit, and Supreme Court disagreed. Section 5110(b)(1) is not subject to equitable tolling. Equitably tolling one of the limited exceptions would depart from the terms that Congress “specifically provided.” The exceptions do not operate simply as time constraints, but also as substantive limitations on the amount of recovery due. Congress has already considered equitable concerns and limited the relief available, aware of the possibility that disability could delay an application for benefits. View "Arellano v. McDonough" on Justia Law

The First Circuit affirmed the judgment of the district court determining that Act 90, passed by the Legislative Assembly of Puerto Rico in 2019, was preempted by federal law, holding that the district court did not err.Act 90 requires that Medicare Advantage plans compensate Puerto Rico healthcare providers in Puerto Rico at the same rate as providers are compensated under traditional Medicare. Plaintiffs, several entities that managed Medicare Advantage plans, filed suit seeking a declaratory judgment and an injunction barring the "mandated price provision," arguing that the Medicare Advantage Act preempted the challenged provision and that provision was unconstitutional. The district court ruled in favor of Plaintiffs. The First Circuit affirmed, holding that Act 90's mandated price provision was preempted by federal law. View "Medicaid & Medicare Advantage Products Ass'n of Puerto Rico, Inc. v. Emanuelli-Hernandez" on Justia Law

The underlying dispute before the Pennsylvania Supreme Court in this case involved the adequacy of state funding for community participation support ("CPS") services, which were designed to help individuals with autism or intellectual disabilities live independently. The primary issue on appeal related to the exhaustion requirement. The Pennsylvania Department of Human Services ("DHS") issued ODP Announcement 19-024, indicating it intended to change the rate structure for CPS services provided under the Home and Community Based Services (“HCBS”) waivers. Petitioners filed an action for declaratory and injunctive relief, challenging the legality of the new fee schedule and alleged the new reimbursement rates were too low to sustain the provision of CPS services to eligible recipients. Pertinent here, the Commonwealth Court agreed with one of DHS' preliminary objections that Petitioners failed to exhaust their administrative remedies, as required by case precedent, before seeking judicial review. The court acknowledged a narrow exception to the exhaustion requirement whereby a court may consider the merits of a claim for declaratory or injunctive relief if a substantial constitutional question is raised and the administrative remedy is inadequate. It clarified, however, that the exception only applied where the plaintiff raises a facial constitutional challenge to the statute or regulation in question, as opposed to its application in a particular case. Here, the court concluded, the Petitioners were attacking the fee schedule in the Final Notice, which was produced by application of the legal authority cited in that notice, and not advancing a facial constitutional challenge. The court also found Petitioners failed to demonstrate the administrative remedy was inadequate. The Supreme Court affirmed the Commonwealth Court’s order insofar as it sustained the preliminary objection asserting that the Petitioners failed to exhaust their administrative remedies, and dismissed the Petition as to those parties. The order was vacated in all other respects, and the matter was remanded for further proceedings. View "Rehabilitation & Community Providers Association, et al. v. Dept. Human Svcs" on Justia Law

Access Behavioral Health appeals from the district court’s judgment upholding an order of the Idaho Department of Health and Welfare that demanded recoupment of Medicaid payments made to Access. The Department sought to recoup certain payments made to Access because it failed to meet the Department’s documentation requirements. Following an audit of provider billings, the Department found Access billed Medicaid for two codes for services provided to the same patient on the same day without documentation to support its use of the codes. The Department concluded the documentation deficiencies violated IDAPA Rule 16.03.09.716 and the Handbook. The Idaho Supreme Court determined the Department had legal authority to issue recoupment demands to Access. Access failed to demonstrate an entitlement to payment of those funds sought to be recouped. The False Claims Act's materiality requirement was inapplicable to the Department’s administrative action. Finally, laches did not bar the Department’s administrative actions. Judgment was thus affirmed. View "Access Behavioral Health v. IDHW" on Justia Law

The Mississippi Division of Medicaid (DOM) and Yalobusha County Nursing Home (YNH) disputed four costs submitted for reimbursement by YNH in its fiscal year 2013 Medicaid cost report. The DOM appealed a Chancery Court’s judgment ordering the DOM to reverse the four adjustments at issue. Because the DOM correctly interpreted the appropriate statutes and because its decisions were supported by substantial evidence, the Mississippi Supreme Court reversed the chancery court’s order and rendered judgment reinstating the decisions of the DOM. View "Mississippi Division of Medicaid v. Yalobusha County Nursing Home" on Justia Law

When Plaintiff-appellant Linda Smith purchased a prescribed continuous blood glucose monitor (CGM) and its necessary supplies between 2016 and 2018, she sought reimbursement through Medicare Part B. Medicare administrators denied her claims. Relying on a 2017 ruling issued by the Centers for Medicare and Medicaid Services (CMS), Medicare concluded Smith’s CGM was not “primarily and customarily used to serve a medical purpose” and therefore was not covered by Part B. Smith appealed the denial of her reimbursement claims through the multistage Medicare claims review process. At each stage, her claims were denied. Smith then sued the Secretary of the Department of Health and Human Services in federal court, seeking monetary, injunctive, and declaratory relief. Contending that her CGM and supplies satisfied the requirements for Medicare coverage. Instead of asking the court to uphold the denial of Smith’s claims, the Secretary admitted that Smith’s claims should have been covered and that the agency erred by denying her claims. Rather than accept the Secretary’s admission, Smith argued that the Secretary only admitted error to avoid judicial review of the legality of the 2017 ruling. During Smith’s litigation, CMS changed its Medicare coverage policy for CGMs. Prompted by several adverse district court rulings, CMS promulgated a formal rule in December 2021 classifying CGMs as durable medical equipment covered by Part B. But the rule applied only to claims for equipment received after February 28, 2022, so pending claims for equipment received prior to that date were not covered by the new rule. Considering the new rule and the Secretary’s confession of error, the district court in January 2022 remanded the case to the Secretary with instructions to pay Smith’s claims. The district court did not rule on Smith’s pending motions regarding her equitable relief claims; instead, the court denied them as moot. Smith appealed, arguing her equitable claims were justiciable because the 2017 ruling had not been fully rescinded. The Tenth Circuit agreed with the Secretary that Smith’s claims were moot: taken together, the December 2021 final rule and the 2022 CMS ruling that pending and future claims for CGMs would be covered by Medicare deprived the Tenth Circuit jurisdiction for further review. View "Smith v. Becerra" on Justia Law